Member Case Study: How does one tell the difference between a groin pull and a stress fracture in the pelvis?

I'm kind of afraid to go back to running if it is a stress fracture. But if it isn't, then I don't want to under-train either. What other symptoms distinguish each of these two injuries?

Question from workoutbunny:

How does one tell the difference between a groin pull and a stress fracture in the pelvis?

A little history: During a 5 mile run last week, I began to feel a dull ache in my pelvic area during mile 4. Being the dorkwad that I am, I tried to run through it...but as I ran, the pain became much worse, and after about 1/2 a mile, I had to stop running and limp home. I iced the injury, and rested for the rest of the day...but by day two I was hurting pretty bad - so I made an appointment with my less than perfect HMO to have it looked at. Without taking an x-ray, the doc said he thinks I strained an adductor muscle, and that within a couple of weeks, I should be ok.

I decided to search the internet to find out what a 'groin sprain' was so I could do whatever necessary to prevent one in the future. However, during my searching, I found that my symptoms really mimic what people who have pelvic stress fractures feel. I do seem to getting better, and can almost walk without a limp now. The most problematic symptom I have occurs when I bend forward and lift the offending leg—it hurts and I have a really tight feeling in the pelvic area. When resting, I have just dull ache in the area (although it is not overwhelming), and there is an area of tenderness in the pelvic bone. I'm kind of afraid to go back to running if it is a stress fracture. But if it isn't, then I don't want to under-train either. What other symptoms distinguish each of these two injuries? My HMO is no help at all.

Answer

Neeru Jayanthi, M.D.Member, AMSSM

Injuries to the groin in athletes can originate from a variety of mechanisms. What is often mistaken for a typical “groin pull” can in reality be a far more debilitating condition. The specificity of the diagnosis is important in order to best tailor a treatment plan, and consideration should extend beyond musculoskeletal causes, particularly in the female athlete. The most important components of an evaluation include a detailed training, musculoskeletal and medical history. This should be followed with a comprehensive physical examination, and selective imaging and laboratory testing at the discretion of the evaluating physician. Ultimately, a specific diagnosis should be reached, and appropriate treatment instituted.

The initial evaluation of groin pain, particularly in a training athlete, should begin with an investigation of workout schedules. The volume of exercise, the extent of cutting, pivoting and weight bearing activities, and the athlete’s level of experience allows the sports medicine physician to begin to elucidate the potential risk factors for certain conditions. Abrupt changes in training volume, prior traumatic injury, or chronic unresolved groin pain seem to correlate with some potential musculoskeletal etiologies. A medical review of symptoms including gastrointestinal symptoms, urinary symptoms, gynecologic history for females, and even a sexual history may reveal some potential medical causes. Occasionally urine or gynecologic cultures, or other blood testing may be indicated if a medical source is strongly suspected.

A sports medicine physician can perform a detailed comprehensive physical examination that will include a back exam, hip exam, neurological exam, focused strength testing, flexibility analysis, and palpation of specific structures within the hip, groin and pelvis. Examination of the abdomen, genitourinary system, hernia examination, and even a pelvic examination may be performed as appropriate. X-ray of the pelvis can reveal arthritis change, some stress fractures, changes consistent with pubic bone pathology, or other types of bony injury such as avascular necrosis (local death) of the bone. Lastly, advanced imaging such as MRI is highly sensitive to diagnose pelvic stress fractures, osteitis pubis (pubic inflammation), labral (hip cartilage) tears, and certain adductor (groin muscle) injuries. One should note that often hernias, particularly sports hernias which arise from weakness in the posterior abdominal wall are not evident on any of this imaging.

Typical groin (adductor) strains usually have some tenderness near the insertion of the muscle/tendon unit near the pubic bone. Some weakness and pain with resistance is often noted. Appropriate stretching of the groin, and concentric (pushing in) exercise targeting the adductor muscles will help improve this relatively benign condition.

Athletes in-training are often concerned with causing serious injury, or aggravating pre-existing conditions that may become chronic problems. Among these are stress fractures that arise in the pelvic region such as the femoral neck, pubic ramus, and sacrum. Typically such stress fractures cause significant pain with weight bearing activities, and are directly related to increases in training volume. Limping may result after even short runs, and pain with activities of daily living such as walking may be indicative of this condition.

Specific treatment depends on location, but in most cases, protected weight bearing for a number of weeks, and gradual return to activity in a structured, supervised program is the hallmark of treatment. Another chronic condition which seems to cause pain more often in those athletes who are involved in cutting and pivoting activities is osteitis pubis. This inflammation of the pubic bone in the pelvis is often caused by shear stress across the pubic symphyseal joint, and can sometimes take 6-9 months to heal. Pain is usually caused by motions that seem to create traction across the joint such as cutting moves. Cross-training, use of a progressive, supervised rehabilitation program, and selective use of steroid injections may help to accelerate recovery from this condition.

Hernias are conditions that may be overlooked as musculoskeletal causes are being investigated. A typical inguinal hernia, which may be the result of congenital abnormalities of the inguinal region, is a relatively common condition in the general population. Sports hernias, which are a result of weakness of the posterior lower abdominal wall, may give athletes such as soccer and hockey players groin pain with straining and high level activities. Often, a physical exam is unrevealing, and all imaging studies are normal. A strong suspicion for this condition should be entertained in any athlete with groin pain that persists for more than three months, particularly in males.

Athletes who have persistent symptoms should be evaluated by a surgeon with experience treating this condition. The referring sports physician can help facilitate this when necessary. Isolated sensory nerve entrapments in the pelvis can sometimes be the source of groin pain with exercise. Diagnosis involves a high index of suspicion and is usually made with the aid of nerve conduction testing after other forms of diagnostic testing have proved unrevealing. Management of this problem varies from targeted stretching to steroid injection or even surgical release of the entrapped nerve.

Other conditions such as labral tears of the hip or various snapping hip syndromes can cause mechanical symptoms such as clicking, popping, or snapping. Labral tears may present with reproducible, sharp groin pain when the hip is moved in certain positions, with or without a click. Although x-ray of the pelvis is typically normal, a special test called an MR arthrogram (an MRI with dye injected directly into the joint) can demonstrate such tears accurately. Arthroscopic surgery is often the most reliable treatment for this painful condition. Tendons of the iliopsoas and iliotibial band may cause a “snapping” sensation as they glide over certain bony structures in the pelvis. These are usually benign conditions, and some specific rehabilitation techniques may alter the biomechanics enough to alleviate the pain associated with them.

It should be apparent that there are a variety of causes that may contribute to groin pain symptoms. Without a detailed historical and physical exam evaluation, it may be difficult to accurately diagnose the condition involved. With appropriate evaluation, an expedited return to activity is usually possible.

Author

AMSSM

The American Medical Society for Sports Medicine (AMSSM) was formed in 1991 to fill a void that has existed in sports medicine from its earliest beginnings. The founders most recognized and expert sports medicine specialists realized that while there are several physician organizations which support sports medicine, there has not been a forum specific for primary care non-surgical sports medicine physicians.

Author

AMSSM

The American Medical Society for Sports Medicine (AMSSM) was formed in 1991 to fill a void that has existed in sports medicine from its earliest beginnings. The founders most recognized and expert sports medicine specialists realized that while there are several physician organizations which support sports medicine, there has not been a forum specific for primary care non-surgical sports medicine physicians.